Scaling Up PECADOM+

04.16.2013

Having now been here for over a year, patterns are starting to emerge. It’s now April again. April means a lot of things: one of the hottest months of the year, saying goodbye to our friends and mentors who came a year before us and meeting those who will replace them, the ripening of mangoes, and Blog About Malaria Month.

Last year at this time, I was still in the midst of Pre-Service Training and wrote my BAMM blog as a way of sharing information from the big paper I wrote for Tulane before coming about malaria prevention and control in Senegal. Since then, my experience with malaria has gone from writing papers about a disease to living through rainy season in Kedougou and watching almost half of my family contract this same disease. It has gone from theoretical to personal.My family members that got malaria last rainy season.

Samouro

Diabou

Kharifa

Sadio

Soba

Tooumany

Now, in April, as we prepare for the upcoming rainy season (typically June through October in Kedougou), I am using my personal experience from the last year as motivation to put in the work necessary to pull off a really exciting project. I am also drawing on my theoretical training from both Tulane and Peace Corps in the design of this project.

Last year in October, I wrote about helping out with a project that dear friend Ian dreamed up and carried out in his area. As soon as Ian told me about the project last May, it sounded too good to leave in just the five villages where he was working, and I told him from the beginning that I was interested in working on scaling it up during the next rainy season. It turns out that I was not the only to recognize the project’s potential. It has gotten a lot of attention from both Peace Corps and the Senegalese health system, both on the ground here and at the national level.

So here’s the concept: In 2008, Senegal introduced a program called PECADOM (Prise en Charge à Domicile or Home Based Management), where villages that are at least five kilometers away from a health post elect someone from their village to be trained to become a DS-DOM (Distributeur de Soins à Domicile or Home-based Care Provider). These people receive very basic training on the signs and symptoms of uncomplicated and severe malaria, how to administer a Rapid Diagnostic Test (RDT), how to treat uncomplicated malaria with medication known as ACTs, and when to refer a case of severe malaria to the health post. They are then given a backpack with RDTs and ACTs (which are both available free of charge in Senegal) and sent back to their villages as a way to address the multiple barriers (primarily geographic and financial) to treatment seeking. In the pilot of the program, no malaria deaths were seen in any villages where PECADOM had been introduced. A 2009 study of PECADOM’s potential showed that in the regions where the program had been introduced, malaria-related hospitalizations were reduced by 43.1%, and malaria-related deaths dropped by 62.5%.

This program clearly has made an impact in the hardest to reach places, but there are some gaps. It is largely a passive model: the DS-DOMs are given their supplies but have no action plan. They go about their lives and wait for the population to come to them if they are sick. As I have discussed before in this blog, treatment seeking is a difficult issue here (http://lineoverthee.blogspot.com/2012/10/no-easy-answers.html) Last spring when he was out on a run, Ian conceived of a way to transform PECADOM into an active model, which in turn came to be known as PECADOM Plus. In the final iteration of this model, the DS-DOMs do a weekly sweep of all of the households to find anyone presenting symptoms of malaria. Anyone complaining of symptoms gets their temperature checked to verify. If they do in fact have a fever, a Rapid Diagnostic Test is given. A positive diagnosis with no signs of complication means immediate treatment with ACTs. Negative tests are referred to the health post for the nurse to find and treat the source of the fever. Any severe cases are also referred, since severe malaria needs to be treated with intravenous quinine instead of ACTs. As opposed to the volunteer work of the DS-DOMs in the orginal model, Pecadom Plus DS-DOMs are paid a small per diem to do the weekly sweeps, since it takes up a day during the rainy season that they could be farming.

Newly Trained DS-DOMs

Community education to supplement the sweeps. Women were trained to identify signs and symptoms of malaria and to encourage treatment seeking.

The idea was to implement this project in the 5 villages that are covered by the health post in his village. On the first day of the project alone, 148 people were tested for malaria, and 88 were positive. 87 people received free treatment on the spot, and one was referred to the health post for severe malaria. On the other hand, the health post treated 368 cases of malaria throughout the entire rainy season, illustrating the gap in malaria control caused by a lack of treatment seeking.

Getting ready to do a Rapid Diagnostic Test during a village sweep

Pat fording a river separating one of the project villages from the health post. Barrier to access to care? I think so.

After that first day, unfortunately, a district-wide shortage of RDTs and ACTs obligated the decision to only implement the project in one village. The weekly sweeps were continued, therefore, in Sekhoto, while the other villages continued with the regular PECADOM model. At the end of the rainy season, we went back for a final sweep Sekhoto and Touba Couta and Khouleya, 2 neighboring villages, to compare the results. On the first day of sweeps in July, the malaria prevalence was estimated by our sweeps at 10.7% in Sekhoto and 9.7% in Touba Couta. On the day of final sweep in November, however, the prevalence had dropped in Sekhoto to 0.9%, while in Touba Couta and Khouleya, it was 7.7%. This is a big difference.

Graph from Ian’s presentation on the project that he was asked to present to the National Malaria Control Program

Seeing this success, where do we go from here? That’s where I come in, conveniently placed at the Health District level. The results from Ian’s project are very promising, but the sample size is very small. I am currently working with the Saraya Health District, Peace Corps, and the President’s Malaria Initiative on a study protocol for the scale-up of this project. There have been many issues to consider: how many villages do we need to make it in order to have a sample size big enough to be confident that the results we are seeing are actually representative of the reality? How many villages can we realistically provide tests and medications for, since this project is obviously going to demand more? Should we target all age groups or just the most vulnerable groups, like children and pregnant women? How can all this be financed? Is it possible to randomize the villages selected to get more statistically powerful results? What is the role of Peace Corps Volunteers? Should we train new DS-DOMs or just use existing ones? Are there villages that are too big or too small for the project to work? How would this work in the gold mining villages? What are the outcomes of interest here? Number of cases detected? The time elapsed before diagnosis? The mean severity of malaria? The prevalence in villages with and without the program during pre and post sweeps? The weekly incidence during sweeps? And how will we measure all of things?

Taking all of these factors into consideration, we are working to put together a protocol as soon as possible in order to (Inshallah) conduct trainings and June and start sweeps in July. Tulane requires Masters International students to choose one project to be their practicum, and this will be mine. Sadly, Ian will be leaving us in May, so it will be up to the remaining health volunteers in the Saraya Health District to bring his baby into toddler-hood. And with the results we can show with this bigger pilot, who knows where this project will go, and how much disease and death it can prevent! To check out other Blog About Malaria Month entries from volunteers across Africa or to learn more about Peace Corps’ Stomping Out Malaria in Africa Initiative, go tostompoutmalaria.org or http://www.facebook.com/StompOutMalaria.